Provider Demographics
NPI:1598761413
Name:DENGERINK, DOUGLAS DEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:DEAN
Last Name:DENGERINK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5244
Mailing Address - Country:US
Mailing Address - Phone:619-229-3909
Mailing Address - Fax:619-229-3902
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5244
Practice Address - Country:US
Practice Address - Phone:619-229-3909
Practice Address - Fax:619-229-3902
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9206207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGL046ZOtherMEDICARE PTAN
CA020A92060Medicare ID - Type Unspecified
CAI30723Medicare UPIN